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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493505
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:27:24 PM

Document Has Been Signed on 11/16/2022 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:GRIGORYAN FAMILY CHILD CAREFACILITY NUMBER:
197493505
ADMINISTRATOR:GRIGORYAN, MARIAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(747) 203-4937
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
11/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mariam Grigoryan - LicenseeTIME COMPLETED:
04:50 PM
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On 11/16/2022, at 3:00pm Licensing Program Analyst (LPA) Suzette Ornelas conducted an unannounced visit to the above address for the purpose of amending the LIC9099D page that was recorded on 11/14/2022. LPA met with Mariam Grigoryan, Licensee and explained the purpose of the visit.

LPA Ornelas observed 10 children in care and 2 adults.

LPA Ornelas informed licensee that the reason for the visit was to amend the LIC9099D page due to having written the incorrect regulation number by missing one digit. LPA explained that it was correctly written on the LIC9099 report but a digit was missed when the regulation number was written on the LIC9099D page. The LIC9099D page should have had the regulation number: 1012423(a)(4) instead of 101243(a)(4). Licensee agreed to sign the amended page; however, due to not having internet access, LPA was unable amend page. Two copies of the amended page will be mailed to licensee who will then return 1 signed copy to the El Segundo Regional Office and keep one for her records. After speaking to her attorney, licensee agreed.

LPA informed the licensee that she is required to notify parents of enrolled children within 24 hours of the Type A deficiency and obtain the signed LIC9224. Licensee stated she was in the appeal process. LPA proceeded to inform her that regardless of an appeal she is required to post the report for 30 days and notify all parents within 24 hours. Licensee stated she was in the appeal process.

Exit interview was conducted. Notice of site visit was given.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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